In pregnancy

Assoc.Prof.Pawin Puapornpong.

Faculty of Medicine

Srinakharinwirot University

Epidermiology

In the past , rheumatic heart disease accounted for the majority of cases. Now ,congenital heart diseases constitute at least half of all cases. Hypertensive heart disease has becomes relatively common cause of peripartum heart failure.

Physiology

Increase cardiac output 30%-50%,เพิม่ ½

of total at 8 wk and then maximize at midpregnancy. Decrease vascular resistance Increase PR,stroke volume,diastolic filling time. Normal left ventricular filling pressure by dilated ventricle.

Hemodynamic change in normal pregnancy

Parameter change (%) Cardiac output +43 HR +17 Left ventricular stroke work index +17 Vuscular resistance Systemic -21 Pulmonary -34

Mean arterial pressure +4

Colloid osmotic pressure -14

Diagnosis

Difficult to diagnose,because murmur ,edema ,dyspnea are common in pregnancy.

Symptoms

Progressve dyspnea or orthopnea

Nocturnal cough

Hemoptysis

Syncope

Chest pain

Clinical Findings

Cyanosis

Clubbing of fingers

Persistent neck vein dilatation

Systolic murmur grade 3/6

Diastolic murmur

Cardiomegaly

Persistent arrhythmia

Persistent split-second sound

Criteria for pulmonary hypertention

Diagnostic study

EKG diaphragm is elevate,15-degree left

axis deviation,mild ST change Atrial and ventricular premature contraction are common in normal pregnancy. Chest X-rayslight heart enlargement

cannot be detected. Echocardiographynoninvasive,some

normal pregnancy inducdes TR and increase left atrial size.

Clinical classification

Class 1 –no limitation of physical activity

Class 2 –slight limitation of physical activity

Class 3 –marked limitation of physical activity

Class 4 –inability to perform any physical activity without discomfort.

Risks for maternal mortaliity

Group 1 –minimal risk 0-1% ASD,VSD PDA Pulmonic or tricuspid disease TOF,corrected Bioprosthetic valve MS,NYHA classes 1 and 2

Group 2 –Moderate Risk 5-15%

2A:MS,NYHA class 3 and 4

AS TOF ,uncorrected Marfan syndrome , normal aorta Previous MI Aortic coarctation without valve involvement

2B:MS with AF Artificial valve

Group 3 –Major risk 25-50% Pulmonary hypertension Aortic coarctation with valvar involvement

Marfan syndrome with aortic involvement

Management of classes 1 and 2

Mortalities rate is low. หลีกเลี่ยง infection - heart failure

No smoking ท าให้เกิด respiratory tract infection งด illegal drug bacterial endocarditis

ระวังภาวะ CHF persistence basilar rales ,

nocturnal dyspnea,Tachytcardia , hemoptysis , progressive edema

Labor and delivery

Normal labor , C/S ถ้ามี indication

Pulmonary artery catheterization

Continuous epidural block เพื่อหลีกเลีย่ง hypotension

Semirecumbent position

Record vital sign keep PR <100,RR<24

F/E , V/E

Intrapartum heart failure

จะรักษาภาวะ heart failure จะต้องรู้ pathophysiology

Puerperium • ระวังสิ่งกระตุ้น Heart failure, Hemorrhage ,

anemia , infection

• Tubal sterilization ควรท าหลังจากคลอดเมื่อ stable

Management of class 3 and 4

High mortalities rate Admit and bed rest is necessary Epidural analgesia is recommended

Surgically corrected heart disease

Sx in childhood , 15-20% not Sx because asymptommatic

complication : thromboembolism or hemorrhage from anticoagulant

Warfarin prevent embolism but teratogenic ,heparin 6-12wk and then continuous warfarin

stop anticoagulant before delivery

start 6 hr if NL and 24 hr if C/S

Valvar heart disease

Type Cause Pathophysiology Pregnancy

Mitral stonosis Rheumatic LA dilate, PH , AF HF from fluid Mitral insufficiency Rheumatic LV dilate improve LV dilate Aortic stenosis congenital LV hypertrophy, life-threatening bicuspid valve decrease CO wlth preload Aortic insufficiency Rheumatic LV hypertrophy improve congenital and dilate connective tissue

Mitral stenosis

Rheumatic endocarditis causes ¾ in MS.

LV dilate and PH from increase preload

Clinical – dyspnea , fatique , palpitation , cough , hemoptysis , tachycardia ลด diastolic filling time ต้องรักษา b- block

AF –aortic embolization , CVA cardioversion

Management

Limit activities ,Sodium restrict , diuretic

New onset AF verapamil or electrical

cardioversion

Chronic AF b- block , digoxin , heparin

Vaginal delivery and epidural analgesia

Prophylaxis endocarditis

Mitral insufficiency

No symptom

Improve in pregnancy because decrease peripheral resistance is reduced regurgitation

HF develop from tachyarrthmia Rx by

b- block

Prophylaxis endocarditis

Aortic stenosis

Disease of aging.

LV hypertrophy , decrease preload decrease CO อันตราย

Chest pain , syncope , heart failure , suddend death from arrythmia

Severe AS extremely dangerous

Management

Asymptomatic no Rx but observation only

Limitation activities and Rx infection

Balloon valvulotomy is high complication

ระวัง hypotension , maintain CO

Epidural analgesia

V/E and F/E

Prophylaxis endocarditis

Aortic insufficiency

LV hypertrophy and dilatation

Fatigue , dyspnea , edema

Improve in pregnancy

If HF Rx sodium restrict , rest , diuretic

Epidural analgesia

Prophylaxis endocarditis

Congenital heart disease

ASD

Risk of ASD in fetus 5-10 %

Congenital asymptomatic until third or

forth decade

PH is rare

If CHF develop Rx

Prophylaxis endocarditis

VSD

Spontaneously close in 90% during childhood

Adult with unrepaired large defect develop HF and PH

If turn to Eisenmenger syndrome , mortalities rate is 30-50%.

Prophylaxis endocarditis

PDA

Some woman with an unrepaired persistent ductus develop PH.

หลีกเลี่ยง hypotension reverse blood flow

from pulmonary a. to aorta cyanosis

Prophylaxis endocarditis

TOF

Cyanotic heart

Large VSD , RV hypertrophy ,overiding aorta

Peripheral resistance decrease shunt

and cyanosis worsens

Hypoxia , polycythemiapreterm , fetal

death , LBW

Eisenmenger syndrome

Secondary pulmonary hypertension

Rt to Lt shunt

Most common : ASD , VSD

Prognosis depend on severity

Pulmonary hypertension

Primary and secondary

Limited activities , avoid of supine position , diuretic , oxygen supplement and vasodilate therapy

venous return and Rt ventricular filling maternal death

Epidural analgesia

Mitral valve prolapse

Connective tissue disease

15% in normal young women

asymptomatic , rare symptom : palpitation , dyspnea

clinical improve in pregnancy

antibiotic prophylaxis

Peripartum cardiomyopathy

Dx by exclude

peripartum heart failure but no underlying heart disease

Bx : myocarditis

precipitate:anemia , infection , preelampsia

Idiopathic cardiomyopathy in preg

Prolong b -mimetic tocolytic provoking cardiomyopathy

symptom : CHF , dyspnea , orthopnea , palpitation , chest pain

Echocardiogram : EF < 45% , increase end- diastolic dimension

Rx : heart failure

idiopathic prognosis better than identifies cause

Infective endocarditis

Subacute endocarditis viridan gr. Streptococci. And Enterococcus species

Acute endocarditis coaglase positive staphylococci , S. aureus in native valve or iv drug abuse , S. epidermis in prosthetic valve , Strep pneumoniae and N. gonorrheae in acute and fulminant

Sign and symptom

Flu – like , anorexia , fatique , embolic lesion ,+blood colture

Negative echocardiographic not exclude

Rx most viridan :penicillin G iv and gentamicin 2 wk

Allergy for penicillin :cef – 3 or vancomycin 4 wk

Other organism C/S 4-6 wk

Prosthetic valve 6-8 wk

Antimicrobial prophylaxis

Moderate-high risk

Normal labor not indication for antibiotic prophylaxis

Preterm , PROM , manual placenta removal , 4 degree tear and high – moderat risk must take antibiotic

High risk

Prosthetic heart valve

previous endocarditis

complex congenital cyanotic heart disease

surgically constructed systemic pulmonary shunts

Moderate risk

Most other congenital malformation not in high or low risk categories

acquire valve dysfunction

hypertrophic cardiomyopathy

mitral valve prolapse with valve regurgitation

Not recommended

ASD

surgically corrected without prosthetic valve

coronary a. with previous bypass Sx

mitral valve prolapse without valve regurgitation

physiologic murmur

pacemaker

previous rheumatic without valve dysfunction

Antibiotic

High risk : ampicillin +gentamicin

Penicillin-allergic patients : vancomycin +gentamicin

Moderat risk : amoxycillin or ampicillin

Arrhythmia

Bradyarrhythmia : permanent artificial pacemaker

SVT: Rx like non pregnancy , digoxin , adenosine , calcium channel blocker

VT : cause ? , b- block

AF : underlying? , digitalis to control rate

Coarctation of aorta

Hypertension in upper extremities and normal or reduced in lower extremities

Hypertension อาการแย่ลง aortic rupture

B- block to prevent hypertension

C/S is recommended

Prophylaxis endocarditis

Marfan syndrome

Autosomal dominant

Systemic connective tissue disease AR ,

MR , aortic dissection

C/S if valve dissection

50% offspring

Aortic dissection

Severe chest pain , loss in peripheral pulse , murmur

Abnormal CXR and angiogram is definite

Noninvasive iv CT or MRI

Rx reduce BP

MI

Rx like non pregnancy

Nitroglycerine , morphine , lidocain calcium channel blocker , b- block

C/S if indication

Epidural analgesia

Thank you